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Burnett County Office of Zoning Administrator d CD 0 0 <br /> _gDPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H -^ iDp <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> o <br /> CD <br /> . .... r ''.?Q ................... � � ........� t..................... <br /> Q <br /> OINPRIA(4pleaCse p.rint)...��� CONTRACTOR or SURVEYOR or AGENT a <br /> ....... ... ....................... . .. . ' <br /> ADDRESS ADDRESS l + <br /> ........................................ ............................................................ N � <br /> ADDRESS ADDRESS <br /> .................... .......................................... <br /> PHON ,,�. PHONE Qv <br /> ....................................T.............................. ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> }:1. .. ..� ... .: �....5Y 3 ... o <br /> ......................................................................................... _. <br /> ADDRESS / ADDRESS r4 m �G) <br /> ........... l...c...... . ...... . .: . ................ <br /> PHONE PHONE Z ti r <br /> DESCRIPTION 4. Sanitary Facilities: ° o N <br /> 1. Work: 2. New BuildingDetails No. Bathrooms -° 3 <br /> V <br /> No. Bedrooms r� 0 New Building ....0-\.. Type of Constructi,ggj�, <br /> Addition utooy? j-fZ Septic Tank Size Gals. <br /> Sanitary \ <br /> ......... .................... ... ........ <br /> y ....�'�.: Size ..�.. .... ft. x ..�.�-.. ft. <br /> Filling .... ., Height.... .. Stori s ...... 4a. Absorption Fieldjte: <br /> Moving 7 �?Area .................... Soil Type ............ �....... : �r <br /> Grading <br /> Slope .....................7.� ....... o <br /> r�-- Perc. Rate .. .. . <br /> Mobile Home 3. Use (describe exactly, 1 family ••• .......... • <br /> PrivyDry Well <br /> ,. �e garage, motel, etc.) """"" <br /> Well ... •• Seepage Trench <br /> Subdivision lT Fd�/v Privy ......... l <br /> .......... .................................................... . : <br /> -------------------------------------------------- Seepage Bed-- ��y�2�.. . �. <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road ;-- <br /> s <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING `' <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ------------------ — ------------------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> �.rc).... ft. x .. © ft. — ...l.��l.�l../..4 ........ sq ft. f�!..�� l C� ................. - <br /> co <br /> N O <br /> ICU �' <br /> As <br /> Thne � ? <br /> • <br /> M cn r W <br /> C <br /> Q <br /> ° b V; m <br /> Z <br /> o <br /> o <br /> . - ... ..... .. ...................................... o C <br /> Signa re of Owner or Agent Date — <br /> Remarks .. m <br /> m <br /> ............................................................................................................ <br /> Inspection Date ....................................... ! - .�, o 0 0 0 o cs m <br /> 000000 <br /> Zoning Admin' trato Q 0000000 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />